State fines North County nursing home $100k

The California Department of Public Health has fined a Rancho Bernardo nursing home $100,000 for poor care that led a dementia patient to choke to death on a mouthful of breakfast foods.

The penalty, assessed against Villa Rancho Bernardo Care Center in inland North County, is the largest that California law allows the department to hand out, according to a statement released Monday.

Called a "AA" citation, the CDPH reserves its most severe penalty for violations "determined to have been a direct proximate cause of death of a patient or resident of a long term care facility."

According to the department, seven AA citations were issued statewide in the 2011-12 budget year, seven in 2010-11, and 17 in 2009-10. A health department spokesman said Monday evening that Villa Rancho Bernardo also had a AA citation in 2010, but the underlying investigative document for that incident was not immediately available.

According to an investigative report, the 61-year-old man who was known to be “a compulsive food seeker” died on Oct. 28, 2012, after cramming two whole pancakes and two whole sausage patties into his mouth at the same time.

“The resident choked on the food and died,” the report states, adding that a doctor’s orders specified that the man’s food be chopped into small pieces to avoid choking.

“The facility failed to follow the physician's orders for a chopped diet,” the report states.

A licensed nurse did not check the food on the patient’s tray and make sure that it had been properly cut into small pieces, the report continues.

“I made a mistake. I was not careful to match the diet card with the food on the plate when I checked the tray,” the nurse reportedly told investigators.

The administrator at Villa Rancho Bernardo did not return a request for comment Monday afternoon, but the state’s investigative report does included a “plan of correction” written by the nursing facility.

The document is careful to state right up front that it “does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth” in the state’s report.

The plan states that the facility reviewed and revised all of the diet orders for its residents following the choking incident.

Starting in November 2012, the plan of correction states, the facility stationed a licensed nurse in its kitchen to examine prepared meals and ensure that they were consistent with all orders before they were delivered to patient rooms.

Compliance with the new plans and procedures is to be reviewed daily with meal accuracy reports reported to administration every month.